青光眼视功能损害及药物治疗研究进展

青光眼是一类以特异性视神经损害和视野缺损为特征的眼病,严重危害患者的视力和生存质量,对青光眼视功能保护的研究对防盲治盲工作具有深远意义,我们就青光眼视功能损害及药物治疗进展进行综述。     

关于青光眼定义之商榷

试图提出一个与目前研究及认识水平相适应的青光眼定义，即“青光眼是由于病理性高眼压以及其他相关因素，引起进行性视神经损害，导致视乳头进行性凹陷性萎缩和视功能、特别是视野损害的一类眼病”。定义强调4点：①视神经对眼压的耐受性有较大的个体差异；②眼压升高的机械压迫和血供障碍共同参与了青光眼的视神经损害，病理性高眼压是主要因素；③青光眼性视神经损害，导致眼底改变的特点是视乳头进行性凹陷性萎缩；④在青光眼性视功能损害方面，视野改变是主要的且具有特征性。本文从眼压、眼底、视野、青光眼视神经损害机制以及视神经保护五个方面对青光眼定义进行了阐述。用比较简明的语言揭示了青光眼的内涵，提出较为全面、科学的青光眼定义。     

利用视野监测青光眼进展需要注意的问题

判断视功能损害进展与否是青光眼临床诊治的基本内容。利用视野监测青光眼进展时需注意的几个主要问题是：如何选择正确的视野检查程序、基线视野检查结果获取的重要性、视野长期波动对利用视野指数判断结果的影响，如何利用视野进展分析软件减少误差、判断青光眼进展需结合的其它临床指标、青光眼视野复查的频度等。     

青光眼早期视功能损害

青光眼是一种常见的致盲眼病,认识青光眼早期视功能损害至关重要。随着检查仪器和检查方法的不断更新,特别是近10多年来计算机自动视野计和多种心理物理学检查方法引入青光眼领域后,青光眼早期视功能损害的研究已取得许多重大进展。本文从青光眼早期视野损害的定义、分期、出现部位等方面介绍了青光眼早期视野损害的研究现状,同时对多种新的青光眼视功能检查进行了评价,最后,从视野缺损发展的途径、方式、危险因素,以及视野缺损逆转的可能性方面综述了青光眼早期视功能损害的转归。     

心理干预对青光眼患者生存质量影响的临床研究

目的 探讨心理干预对青光眼患者生存质量的影响,为青光眼的护理干预提供科学依据和对策.方法 采用视功能损害眼病患者生存质量量表、健康促进生活方式量表和自行设计的焦虑相关因素调查问卷对患者分别在人院前、手术前后、出院前进行评估.结果 实验组和对照组比较,心理干预后实验组与对照组焦虑评分、生存质量总评分、精神与心理方面评分、症状与视功能方面评分以及医患顺应性有显著差异(P<0.01).身体机能、社会活动方面评分无显著差异(P>0.05).健康行为与婚姻家庭状况、文化教育程度、心理干预、经济状况、社会支持、青光眼症状发作显著相关(P<0.01).结论 心理干预可以明显缓解青光眼患者住院期间情绪波动所造成的发作性症状,改善焦虑情绪及心理状态,提高住院期间视功能及相关生存质量.     

青光眼与生存质量的关系

目的:了解青光眼患者视功能损害与生存质量的关系,探讨影响青光眼患者生存质量的主要因素。方法:应用视功能损害眼病生存质量量表测量60例有不同程度视功能损害的慢性闭角型青光眼及开角型青光眼患者的生存质量情况。结果:青光眼患者的视功能改变与生存质量之间存在相关关系(r=0.66,P=0.000),影响青光眼患者生存质量的主要因素是视功能损害,性别及职业。结论:青光眼患者视功能损害降低病人的生存质量,生存质量测量为青光眼筛检及治疗方案选择提供新的指标。眼科学报 1996;12:183～187。     

原发性闭角型青光眼患者心理及人格特征关系的临床观察

目的分析闭角型青光眼患者心理、个性特征与疾病的关系。方法选择在西安市第四医院门诊及住院的西安市青光眼患者100例,分别运用艾森克个性问卷、A型行为问卷以及焦虑和抑郁自评量表对其人格、行为特征和焦虑、抑郁状态进行测试,并与正常对照组进行比较。结果A型行为问卷,青光眼组TH量表得分高于对照组,差异有统计学意义（P〈0.05）,青光眼组TH＋CH和CH得分与对照组无明显差异（P〉0.05）。艾森克个性问卷中青光眼组的精神质（P）、神经质或情绪（N）得分明显高于对照组（P〈0.05）,而内外向、掩饰两项得分青光眼与对照组无显著性差异（P〈0.05）。焦虑和抑郁自评量表中,青光眼组的评分均明显高于对照组（P〈0.05）,并且急性闭角型青光眼患者的焦虑评分与慢性闭角型青光眼患者也有明显差异（P〈0.05）。在相关分析中,青光眼患者的焦虑和抑郁情绪与精神质（P）、神经质（N）、TH和CH＋TH成明显正相关。结论闭角型青光眼患者主要表现为A型性格,患者具有典型的精神性和神经质倾向人格特征;闭角型青光眼患者的情绪受人格和行为特征的影响。     

开角型青光眼药物对患者身心健康的影响

目的:评价原发性开角型青光眼(primary open angle glaucoma,POAG)患者的心理和生活质量状况并分析其影响因素。方法:采用前瞻性临床对照的方法,对60例POAG患者分别采用青光眼生活质量-15中文版(Glaucoma Quality of Life-15,GQL-15)和综合医院焦虑抑郁量表(Hospital Anxiety and Depression Scale,HADS)中文版评定患者最近1mo的生活质量和焦虑、抑郁状况,给予降压药物干预后1mo再次进行评定。60例健康自愿者作为对照,分析其心理和生活质量变化情况。结果:POAG患者焦虑、抑郁及共患患者发生率分别为33.3%,26.7%,13.4%。患者抑郁焦虑评分及GQL评分与病程、眼压、年龄、药物种类和价格成正相关(P<0.05),与平均月收入、视力成负相关(P<0.05)。通过降压药物干预,患者焦虑、抑郁评分及生活质量评分明显好转(F焦虑评分=9.54,F抑郁评分=6.88,FGQL评分=8.82;P<0.05)。结论:POAG患者焦虑、抑郁状况加重,生活质量明显降低。患者抑郁焦虑评分及生活质量评分与病程、年龄、平均月收入、药物种类、药物价格、视力、眼压、视野等方面紧密相关。降压药物干预有助于青光眼患者生活质量和心理逐步康复。     

新型视野检查法的研究和应用进展

视野检查是眼科临床主要的视功能检测手段之一.如今常规的计算机视野检测已得到普遍应用,在青光眼、视神经病变等眼病的诊断中发挥着重要作用.但对于一些较早期的眼部病变,通过常规的计算机视野检测仍然无法发现最早期的视野缺损变化.因此,反映不同眼疾视功能损害特征的短波长视野、运动觉视野、倍频视野、高通分辨和模型辨别视野、自动瞳孔视野、闪烁视野、微视野等多种新型视野检查方法被相继开发.本文对这些新型视野检查的研究和应用进展作一综述.     

OCT测量视网膜神经纤维层厚度在青光眼诊断中的研究进展

青光眼是一种进展性视神经疾病,它能引起视神经结构改变,最终导致不可逆视功能损害。青光眼的早期诊断对保护视功能有重要的意义。光学相关断层扫描仪可以定量检测视网膜神经纤维层厚度,为早期诊断青光眼,监测视神经损害及指导青光眼的治疗提供了新的思路。本文主要反映该技术在青光眼诊断中的研究进展。许多研究都发现光学相关断层扫描仪检测的视网膜神经纤维层厚度在有视野改变的青光眼中有明显改变,且与视野损害在位置和严重程度上有很好的相关性,但仍缺乏有力的纵向研究来评价其在无视野改变青光眼中的诊断价值。     

Agreement amongst consultant ophthalmologists on levels of visual disability required for eligibility for certificate of sight impairment: Sight impairment registration using binocular composite visual fields

BackgroundRegistration as sight impaired allows access to services important for patients. The rates of sight impairment due to visual field loss are underestimated. Previous work has shown that evaluation of visual field defects in both eyes produces poor agreement among ophthalmologists for categorisation of patients as eligible for sight impairment registration.AimTo evaluate the impact of binocular summation of both eye glaucomatous visual field defects on agreement for sight impairment registration.MethodsThirty consultant ophthalmologists (Graders), graded 50 glaucomatous visual field sets. Each consisted of both monocular fields and summated binocular plots. Graders classified the visual field sets as sight impaired (SI), severely sight impaired (SSI) or neither. Trichotomous, (SI, SSI or no sight impairment) and dichotomous (any sight impairment versus no sight impairment) concordance values were estimated for the group of graders as a whole and for glaucoma and non-glaucoma experts.ResultsFor trichotomous analysis the overall kappa agreement rate was 0.29; for dichotomous analysis it was 0.40. There was no material difference between glaucoma experts and non-experts.ConclusionOverall agreement was modest. Grading for SI showed the poorest levels of agreement. Using binocular fields does not appear to improve concordance for sight impairment registration. Moreover, there is no difference in agreement between glaucoma and non-glaucoma experts. An overall score for visual disability using mean deviation may be a more pragmatic approach.Subject terms: Eye diseases, Education     

Electrocardiographic changes in institutionalized geriatric glaucoma patients

A geriatric study was conducted on 213 institutionalized geriatric glaucoma patients (mean age 83.9 years) and 100 control patients (mean age 81.3 years). A 12-lead electrocardiogram (ECG) analyzed according to the Minnesota code was recorded for 212 glaucoma patients and 95 control patients. The most frequent finding (in 56% of the glaucoma patients and in 38% of the control patients, P < 0.05) was a negative or isoelectric T-wave, suggestive of ischemic heart disease. ECG findings suggestive of coronary heart disease (Q/QS patterns, ST-segment depression, negative or isoelectric T-wave, third or second degree AV block, left bundle branch block or right bundle branch block, intraventricular block or atrial fibrillation or flutter) was seen significantly more often in glaucoma patients (164/212; 77%) than in the control patients (59/95; 62%). Seventeen percent of the glaucoma patients had atrial fibrillation (AF), which was significantly more than for the control group (8/95; 8%). There was no difference in the number of ECG changes between patients with bilateral open-angle glaucoma and bilateral angle-closure glaucoma. The mean intraocular pressure of patients having AF (15.9 ± 8 mmHg) was significantly lower than that of the other patients (18.4 ± 11 mmHg) (P < 0.05). Fifty-five glaucoma patients were considered blind (visual acuity < 0.05 in the better eye). The visual acuity of patients having AF was lower than that of the other patients, and severe visual field defects (arcuate scotoma or a residual field in the temporal periphery) occurred, slightly more frequently in patients with AF (in 70% vs 51% of the other patients). Arrhythmias, especially AF, are connected with impairment of visual acuity and visual field defects in glaucoma patients. The result of this retrospective study indicate that ECG changes occur frequently, suggesting coronary heart disease in elderly glaucoma patients.     

心理干预对闭角型青光眼患者心理和视野及眼压的影响

目的:评估心理治疗对闭角型青光眼患者心理、视野及眼压的影响。方法:运用SCL-90、焦虑和抑郁自评量表对100例闭角型青光眼患者进行问卷调查,并在术后3mo对患者的视野、眼压和HRTⅡ进行检查。结果:通过一定的心理干预后,干预组SCL-90量表中人际关系、抑郁、焦虑、恐怖和偏执等指标评分较非干预组有所改善。干预组与非干预组相比,焦虑和抑郁评分明显改善,差异具有统计学意义(P<0.05)。术后3mo,干预组患者的眼压较非干预组低,差异具有统计学意义(P<0.05),但干预组与非干预组的视野平均缺损和模式标准差无显著性差异。HRTⅡ中的指标,干预组中C/D和线性C/D与非干预组有显著性差异外,其余指标均无明显差异。结论:心理干预对闭角型青光眼患者的治疗作用只能是在药物和手术治疗的基础上起一定辅助作用,提高药物、手术治疗的疗效。     

Melatonin concentrations in serum of primary glaucoma patients

AIM: To determine whether glaucoma patients exhibit an abnormal melatonin concentration in serum and the effects of psychiatric disorders caused by glaucoma in melatonin secretion. METHODS: A sample of 80 primary angle-closure glaucoma (PACG) patients, 120 primary open angle glaucoma (POAG) patients, and 120 normal controls were enrolled in this study. All the participants were asked to complete the following questionnaires: Pittsburgh sleep quality index (PSQI), self-rating anxiety scale (SAS), and self-rating depression scale (SDS). Variance analysis was used to compare the subscores between the groups. After that, we chose 58 patients with primary glaucoma and 20 non-glaucoma control patients to collect their serum samples at 7-10 a.m. Serum melatonin levels were measured using enzyme linked immunosorbent assay (ELISA). RESULTS: Of all participants, the scores of PSQI, SAS, and SDS in PACG and POAG group were 9.38±0.40, 46.08±8.99, 51.11±10.72 and 7.43±0.35, 45.42±9.87, 49.04±12.24 respectively, significantly higher than those in control group (4.16±0.28, 35.49±9.18, 40.31±13.08). The serum melatonin levels in PACG (37.29±2.99 pg/mL) and POAG (35.97±3.64 pg/mL) were significantly higher than the controls (29.96±3.94 pg/mL) (P<0.001). But no difference was found between the PACG and POAG (P=0.216). Glaucoma patients with sleep disorders, anxiety and depression were more likely resulting in the increase of melatonin levels. CONCLUSION: There is a significant increase in serum melatonin levels in glaucoma patients compared to the controls especially in glaucoma patients with psychiatric disorders such as sleep disorders, anxiety and depression.     

原发性青光眼患者心理因素分析

目的探讨原发性青光眼患者的心理特征。方法41例原发性青光眼患者(其中POAG者12例,PACG者29例)和41例正常对照者分别用汉米尔顿焦虑量表(附自评量表STAI),汉米尔顿抑郁量表HRSD(附抑郁自评量表SDS)、躁狂评定量表MRS进行测评,记分项目包括:汉米尔焦虑量表总分A,包括2个因子,精神性焦虑(A1)、躯体性焦虑(A2);STAI表总分用D表示;HRSD表总分用B表示,包括5个因子,焦虑/躯体化(B1)、体重(B2)、认识障碍(B3)、迟缓(B4)、睡眠障碍(B5);SDS表总分用E表示;MRS表总分用C表示,病情程度用病情指数(C0)表示。结果评分并统计进行测评,所有受试者的各量表总分均在抑郁或焦虑症、燥狂状态的诊断分数以下,各量表包含的影响因子得分分析:对照组与原发性青光眼组比较:HRSD表中的体重因子(以体重减少0.5kg加1分记分)得分结果无显著性差异,t=0.47,P=0.643>0.05,青光眼患者体重不受疾病影响而变化,除此因子外,其余12项均有显著性差异(P<0.05),自评量表结果与调查者评分结果一致,显示出青光眼患者心理因素较对照组有明显不同;POAG和PACG比较:MRS表(C)分数有显著性差异,其中焦躁易激惹因子分突出(C0),POAG组因子分明显高于PACG组(P<0.05),其余11项无显著性差异(P>0.05);Logistic回归分析结果:HRSD表中的焦虑/躯体化因子B1、迟缓因子B4、以及SDS表得分结果进入回归方程,得到OR值分别为13.772,11.776,0·577。结论和正常人比较,青光眼患者群在心理评定量表中的多项因子有显著差异,青光眼患者的心理特征和正常人不同。     

图形视网膜电图和图形视觉诱发电位同时记录青光眼及高眼压症的研究

对３０例５０只青光眼、１４例２８只高眼压症进行ＰＥＲＧ和ＰＶＥＰ同时记录。首次发现青光眼和高眼压症的ＲＣＴ延长，同时青光眼组ＡＰ５０、ＡＰ１００下降、ＬＰ１００延长，异常率分别为４６％、５２％￣５４％，高眼压症组ＡＰ５０和ＬＰ１００的异常率均为２８．５７％。青光眼组ＬＰ１００、ＲＣＴ与视野缺损、Ｃ／Ｄ在小呈正相关，ＡＰ１００与视野缺损、Ｃ／Ｄ大小呈负相关，ＡＰ５０与视野缺损呈负相关。本研究从电生理     

Prevalence of end‐of‐life visual impairment in patients followed for glaucoma

Purpose: To assess the prevalence of end‐of‐life visual impairment in patients followed for glaucoma. Methods: Data of 122 patients followed for glaucoma who had died between July 2008 and July 2010 and who had visited the ophthalmology outpatient department of a large non‐academic Dutch hospital were collected from the medical files. Sixty‐one patients had open‐angle glaucoma (OAG), and 61 patients were suspect for glaucoma or had ocular hypertension (OHT). Visual impairment was defined as a mean deviation value <?15 dB or a Snellen visual acuity <0.3 (20/60) of the better eye. We determined the number of patients with visual impairment on the last patient visit before death and investigated its main explanations. Results: Overall, the mean age at death was 81.8 years after a mean follow‐up period of 9.2 years. Seventy‐three per cent of all patients had their last visit in the year preceding death. In OAG, 16 patients (26%) had an end‐of‐life visual impairment. In nine patients (15%), this was caused by glaucoma. Eight of them had substantial visual loss at the initial visit. Six (10%) impaired OAG cases were mainly explained by ocular comorbidity, and there was an equal contribution of comorbidity and glaucoma in one case. Five glaucoma suspects or patients with OHT (8%) were visually impaired at death and these were all caused by ocular comorbidity. Conclusion: The prevalence of end‐of‐life visual impairment is considerable in patients with OAG. Substantial visual loss at baseline is an important contributing factor. In glaucoma suspects or patients with OHT, the prevalence is lower and can be attributed to ocular comorbidity.     

青光眼视野损害的评价方法

青光眼是眼科常见的不可逆性致盲眼病,其主要损害是视网膜神经节细胞（RGCs）及其轴突的变性和丢失,最终可导致视野损害和视力下降。视野检查是青光眼早期诊断以及随访过程中观察病情进展最重要的视功能检查方法,但由于视野检查存在较强的主观性,因此如何建立客观、规范的视野评价和分析方法一直受到青光眼学者们的关注。就目前临床及研究中常用的视野缺损分级方法,包括视野指数、青光眼半视野检测（GHT）、晚期青光眼干预研究（AGIS）评分法、早期青光眼试验（EMGT）评分法、多中心青光眼初始治疗研究（CIGTS）评分法等,及其优缺点进行综述,希望能够对临床及科学研究中视野评价方法的选择有所帮助。     

Screening for Depression and Anxiety in Patients with Active Uveitis

Purpose: To screen for psychological disorders in patients with active uveitis.

Methods: Patients were screened for depression (BDI-II), state anxiety (STAI-I), VR-QOL (NEI-VFQ-25), and HR-QOL (SF-36). Association of depression and anxiety with sociodemographic and clinical parameters and with VR-QOL and HR-QOL were analyzed. Multivariate linear regression models were constructed for NEI-VFQ-25 and SF-36 subscales.

Results: Of 99 patients, 37.3% screened positive for depression and 52.5% for anxiety. Depressed patients had lower visual acuity in the better seeing eye (p = 0.013) and more frequently panuveitis (p = 0.018). Anxious patients were younger (p = 0.009), had earlier onset of uveitis (p = 0.015), and had more frequently panuveitis (p = 0.016). Bivariate comparisons showed significant associations between psychological disorders and VR-QOL and HR-QOL. Significant bivariate associations were mostly lost in multivariate analyses for anxiety, but were preserved for depression.

Conclusions: A positive screening test for depression and anxiety is common in patients with uveitis. Low vision and panuveitis are associated with depression. Depression is associated with impairment of VR-QOL and HR-QOL.     

Impaired motion sensitivity as a predictor of subsequent field loss in glaucoma suspects: the Roscommon Glaucoma Study

AIM—To determine if impaired motion sensitivity is a significant predictor of subsequent field loss in glaucoma suspects.
METHOD—A population based prospective study; a 5 year follow up of all glaucoma suspects who had been identified from a population based random sample survey in the west of Ireland. 78 glaucoma suspects whose visual field function was annually measured by Henson CFS 2000 and for whom data on family history of glaucoma, ocular status, and motion impairment had been recorded. Visual field loss was defined as Henson visual field survival score of 94 or less.
RESULTS—18 people developed visual field loss in at least one eye. Motion impairment at baseline was associated with a 2-18 times greater risk of development of the visual field loss (p<0.001). This association was independent of sex, family history of glaucoma, intraocular pressure, and C/D ratio at baseline. The Cox's proportional hazards regression analysis confirmed the above results after adjustment for age and the C/D ratio.
CONCLUSION—Motion impairment is an independent predictor of visual field loss in glaucoma suspects, although it is not clear how long motion impairment precedes visual field loss.

Keywords: glaucoma; perimetry; screening; motion